Download RESEARCH IN MUSIC THERAPY WITH PATIENTS WITH PERSONALITY DISORDERS

RESEARCH IN MUSIC THERAPY WITH
PATIENTS WITH PERSONALITY DISORDERS
MUSIC THERAPY CLINIC AALBORG UNIVERSITY
H O S P I TA L – P S Y C H I AT RY
N I E L S H A N N I B A L , A S S O C I AT E P R O F E S S O R . P H . D .
Unit for Psychiatric Research
The new Music House in Aalborg: Our new home
WE are here
Hoste:
-  Aarhus Music Conservatory,
-  Music Education Aalborg University,
-  Music Therapy Education (from August 2015)
Who am I?
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Born 1960
Trained nurse 1984
Trained music therapist 1994
GIM level 1 and almost level 2
Done clinical music therapy in psychiatry since 1995
Ph.D. in 2001: Preverbal transference in musical improvisation
Associate professor since 2005
Issues for this presentation
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The RCT and related issues
The Conceptual framework
A case
MBT and music therapy
A pilot-study for music therapy with people with personality disorder
THE RANDOMIZED CONTROLLED TRIAL
The RCT: Randomized controlled trial
•  The RCT - the gold standard for a clinical trial.
•  RCTs to test the efficacy experimental or
effectiveness of various types of medical
intervention in clinical settings
•  Recognized as the standard method for "rational
therapeutics" in medicine. As of 2004, more than
150,000 RCTs were in the Cochrane Library
RCT - normally
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Random allocation,
Sample
Control group,
Independent variable (the intervention)
Dependent variable (the effect)
Blinding
Ethical approvement,
Informed consent
Data registration
Statistical analysis
RCT’s in music therapy: Challenges
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Complex intervention – naturalistic setting
•  The therapist adherence to treatment (manual) and competences (the
level of skill) (Waltz et al. 1993)
Many variables: Specific and non-specific
•  How can we know that music is the active ingrediences
Blinding difficult
•  Can blind assessors but normally not participants
•  The RCT with people with schizophrenia and effect on negative
symptoms
Recruitment problems
•  Population often not able to participate in trails (wont give consent)
•  The problem with referral and assessment
Often MT is compared to TAU
RCT advantages and challenges
1.  Eliminates bias in treatment assignment, specifically selection bias and
confounding.
2.  Facilitates blinding (masking) of the identity of treatments from investigators,
participants, and assessors.
3.  Permits the use of probability theory to express the likelihood that any
difference in outcome between treatment groups merely indicates chance.
4.  Allocation bias (or confounding). May occur when covariates, and the
treatment effect is confounded with the effect of the covariates (i.e., an
"accidental bias
1.  Non-specific factors. For ex. Looking at treatment effect between
therapists (Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Tervaniemi, M., Vanhala, M. &
Gold, C. 2011)
RCT- Music therapy and negative symptoms
Hypoteses: Music therpapy can reduce negative symptoms compared to
being together with a social worker (bostøtte)
Negative Symptoms scale (Panss)
•  Blunted affect
•  Emotional withdrawal
•  Poor rapport
•  Passive/apathetic social withdrawal
•  Difficulty in abstract thinking
•  Lack of spontaneity and flow of conversation
•  Stereotyped thinking
The design
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Double-blind Randomized controlled study using three measurement points
(baseline, after 15 sessions and at the end) .120 participants randomized 1:
1 to either music therapy or time-compensated contact with social worker.
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Randomization is done in blocks with varying block size and stratified by
whether the participant can meet up in a therapy room or need assistance in
the home.
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All participants are offered 25 sessions of music therapy at 1 hour duration
once weekly. The treatment period does not include holidays. Both
participants and assessment personnel carrying out the experimental
procedures are blind, while music therapists, the social worker and
researchers carrying out qualitative analysis, unblinded (as blinding is not
possible).
Music therapy RCT and Meta-analysis
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Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Tervaniemi,
M., Vanhala, M., & Gold, C. (2011). Individual music therapy for depression:
randomised controlled trial. The British journal of psychiatry, 199(2),
132-139.
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Gold, C., Mössler, K., Grocke, D., Heldal, T. O., Tjemsland, L., Aarre, T.,
Aarø, L. E., Rittmannsberger, H., Stige, B., Assmus, J. & Rolvsjord, R.
(2013) Individual Music Therapy for Mental Health Care Clients with Low
Therapy Motivation: Multicentre Randomised Controlled Trial.
Psychotherapy and Psychosomatics, vol. 82, s. 319-331, 2013.
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Gold, C., Solli, H. P., Krüger, V., & Lie, S. A. (2009). Dose–response
relationship in music therapy for people with serious mental disorders:
Systematic review and meta-analysis. Clinical psychology review, 29(3),
193-207.
Questions and issues when wanting to do research in music
therapy field……actually in any complex field/natural setting?
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Can we standardise music therapy?
Are the treatment the same in different settings and countries?
Are our conceptual models for treatment identical?
Is our understanding of the vehicle of treatment comparable?
Is the context similar?
Are our measurement tools valid and translated?
How can we avoid treatment fidelity?
How can we clime effect when we cant give blinded treatment /placebo?
PROMT or MBTMT
THE CONCEPTUAL FRAMEWORK
To Mentalize
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Mentalizing is the process by which we make sense of each other and
ourselves, implicitly and explicitly, in terms of subjective states and mental
processes
When mentalizing is compromised, subjective internal experiences and the
interpersonal world stop making sense
Vulnerability to frequent loss of mentalizing and slower recovery of
mentalization in the context of interpersonal relationships is the fundamental
pathology
(Daubney & Bateman. 2015)
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And frequent loss of mentalization is what happens in for people with
dysfunctional attachment systems and personality disorder
Mentalization in music
Explicit level: To know
•  Words
•  Narratives
•  Images MBT community knows this
•  Symbols
•  Artefacts
•  Music
•  Conscious
Implicit level: To know how
•  Procedural
•  Knowledge of how to be
with other
•  Non-conscious
•  Proto-musicality
•  Musicking
Music:
Aesthetic object/
experience
(Stige 2002)
Proto-musicality:
music as
communication
They don’t know this – but we do!
Musicking:
Music as action
Why does MBT model fit music therapy practice?
here
and
now
tp. and cl.
both
contribute
stimulates
mental
processes
We have been doing
this all the time –
We just used different
theoretical frame
Mentalization
and
expressive
and receptive
music therapy
implicit
relational
patterns
affect/
arousal
regulation
activates
attachment
system
How does MBT change therapist role in analytical music
therapy practice
Different therapeutic focus and
understanding of process
•  Has to be able to mentalize the client
•  Not too “hot” and not too “cold”
•  Always “here and now” focus - context focus
•  The not knowing stance
•  Only mirror marked emotions
•  Use the past to understand the present
•  Monitor mentalization capacity in self and
other
•  Intervene when client experiences a
mentalization breakdown
The therapist don’t
Don't use free association
Don't use of confrontation and
frustration
Don’t mirror unmarked emotions
Testing the integrity of a psychotherapy protocol:
assessment of adherence and competence.
Waltz, J., Addis, M. E., Koerner, K., & Jacobson, N. S. (1993).
How well do therapists adhere to the manual and how competent are they
How can we avoid treatment fidelity
Category 1: Unique and Essential Therapeutic Principles
Category 2: The Essential but not Unique Therapeutic principles
Category 3: Acceptable but not necessary Therapeutic principles
Category 4: Not acceptable – Proscribed Therapeutic Principles
Process Orientated Music Therapy (PROMT)
- now Mentalization Based Music Therapy (MTBMT)
Category 1: Unique and Essential Therapeutic Principles
The therapeutic process:
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is always the central focus of the music therapy work
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can focus on reduction of symptoms and/or development of skills/competencies and/or strengthening of resources
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always takes place in a perspective of ´here and now’ and the past is only involved from this perspective
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concerns both the implicit procedural level and the explicit and declarative level
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is not bound by a certain music therapy method (improvisation, composition, reproduction or music listening)
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the focus of the therapeutic process are relational and communicative competences
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The therapist has to know and be able to maintain “a not knowing stance” in the treatment.
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The therapist should aim at preserving an attitude to the client in the verbal parts, in the musical parts and in the non-verbal
communication, which promotes mutual mentalization.
Category 2: The Essential but not Unique Therapeutic principles
The therapeutic process:
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is identified in dynamic patterns such as defence, transference and countertransference
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necessary to creating, developing and maintaining the therapeutic alliance (cooperation on aims, methods, intimacy and leadership)
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has regulation of arousal as its focus
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can take place by verbal reflection or by musical actions
Category 3: Acceptable but not necessary Therapeutic principles
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Interventions, which curb negative processes and processes, which do not promote the on-going therapeutic process
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Advice and structuring interventions, when the patient cannot cope with the therapeutic process
Category 4: Not acceptable – Proscribed Therapeutic Principles
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Interventions based solely on methodological or theoretical reasons without involving the perspective of the patient
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Application of transference to examine unconscious repetitions of earlier behaviour
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Encouragement of fantasies and free associations about the therapist
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Application of frustrating and confronting interventions such as long silent breaks for example
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Mirroring of non-marked (explicitly) emotions
Integration of MBT into our PROMT manual
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here and now focus
implicit and explicit level of communication
a not knowing stance
strive to maintain a metallization enhancing attitude verbal and musical
identify dynamics patterns such as defence, transference and countertransferences, and
•  only use them to enhance understanding of the on going unfolding
interaction
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•  don't encourage the client to fantasise and use free association about the
therapist
•  don't use confrontation and frustration-inducing interventions such as long
periods of silences
•  don’t mirror unmarked emotions
Name of department…
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The Rational for using music in treatment with people with
bpd
Discussing with Gitta
Music therapy can promote implicit and explicit mentalization
Music therapy can change dysfunctional and inflexible ways of being
with other (WOBWO) persons to more integrated and flexible WOBWO
Our statement:
•  Music provides an in vivo way to access the attachment system, affect
regulation, and there by develops the ability to implicit and explicit
mentalization
•  Musical interaction is lived experience
•  Music creates a relationship between people (affordance) where new
attachment patterns can emerge
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Music can also stimulate the attachment system
in a negative way:
•  Create high arousal and loos of mentalizing capacity
A CASE: LAILA
Laila
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Low self-esteem, feeling unmanageable, sadness and cries easily.
Has been depressed for a long time since her first big love died accidently some 20 years
ago.
She describes her husband as someone she married for safety more then love.
Security is essential to her.
Her farther like to brag about his pretty daughter in front of friends and also same times made
fun and humiliate her when she makes her self pretty.
Mother is dominating and threatens to leave if her opinion is on respected.
She depends on her mother because her husband is a sailor in the merchant fleet.
It is difficult for her to engage with her children and relax at the same time.
She has high demands to her self, and never seem to get a sensation of achievement and
mastery.
She is preoccupied with what other people think about her, or over involved in others.
Diagnosed with
•  F60.0 Paranoid personality disorder;
•  F60.5 Compulsive PD and
•  F61.0 Disturbed personality mixed type
Name of department…
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Possible triggers of mentalisations breakdown
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Her attachment style is ambivalent over involved
•  if she wants admiration - she fears humiliation and exposure
•  if she needs support and help - she won’t have any room for her point
of view
•  if she needs to process loss - she is afraid to be dined comfort in her
grief
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1. session
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40. session
Experience loos of mentalization
Don’t loos mentalization
Name of department…
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At the end of treatment
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She reports experiences her self as more safe in relation to me. Annoyed to
have to start all over aging in another setting.
Is more open and honest.
She is more aware about how she perceive others, and wished she was
less suspicious
Still occupied about what other people say about her. She feels bad but still
sad deep down.
She has begun working a few hours a week and manage this stress.
She has begun to enjoy things and not only focus on if everything is perfect.
Name of department…
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Questions
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What were the active ingrediences in the treatment? Was it the relation, the
expressive or the receptive music interventions
Was it music therapy – or verbal therapy including music? There was a lot
of talking, but the music played a significant role
Was it analytical music therapy, MBT or something else? Non of the
therapist had MBT training
What had changed? Her mentalizing capacity had improved, the ability to
respond and be more flexible in interaction, more autonomous, less
dependent, higher life quality
Was the effect lasting? We don’t know
PILOT-PROJECT II
Timeline
Writingpublishing
Not treatment
Presenting
in Krems
Trip to Finland
MBT training
Consortium
meeting
Cambridge
Consortium
meeting
Lorne
2009
PROMT manual
2010
Depression study
and design
2011
BPD pilot 1: 2 do.
Data collection failed
Treatment
Presenting in
Aalborg,
Philadelphia
2012
BPD pilot 2. 4
pt………………
MBT and music
therapy
Oslo
Consortium
meeting
Krems
Consortium
meeting
Cape May
2014
2015
2016
The second pilot:
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Data collection period: 2012-2014
Pt. pre-post external assessment
40 sessions of treatment (2 session pr. week for 13 weeks, 1 session pr.
week for 14 weeks)
Both expressive (improvisation, songwriting, performing) and receptive
technics (tp and/or cl chosen)
4 pt. participated (one male, tree women)
Research hypoteses
Music therapy can:
•  Strength the clients ability to attachment and there by gradually reducing
anxiety and change destructive thought and actions patterns
•  Contribute to the development of pt’s self confidence
•  Develop pt’s ability to communicate
•  Improve personal integration
•  Improve life quality
•  Improve psychosocial function level
Variables – dependent
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Variables
•  RAAS: Attachment
•  WHO-QOL: Quality of life
•  SOC: Sense of coherence
•  HAQ-II: Alliance
•  SCL-90: Symptoms
•  HADS-anxiety: Symptom
•  IIP: Interpersonal function
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Measure point: Pre, 25 session!, follow up
Findings
Strength the clients ability to
attachment and there by gradually
reducing anxiety and change
destructive thought and actions
patterns
Yes better attachment, but no direct
link to symptoms
Contribute to the development of pt’s
self confidence
Yes self-report
Develop pt’s ability to communicate
Yes
Improve personal integration
Yes
Improve life quality
No
Improve psychosocial function level
No
Issues that needs to be solved
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Meta/design
Theory/
hypothesis
Data/
practice
Design
Resources – applications – money/time
Collaboration local and abroad
Research questions
•  The rational for using music
•  Conceptual framework
•  Manual
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Intervention
Training of therapists – adherence to manual
Variables
Recruitment
Intervention/control gr.
Measure points
Current status
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The treatment manual: Does it work, adherence
The theoretical framework: MBT?
The uniqueness of the music: Why music
The explanatory model: The why question
The research design: RCT with one (improvisation) or several variables
(expressive and receptive)
The training of the therapist:
The future music therapy practice, research and theory in
treatment of personality disorder
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We need some kind of effect study, to hopefully support the clinical impression that MT with this population in
psychiatry is beneficial: PRE/POST, RCT, Mixed method
•  We are working on establishing a research group in collaboration between universities in Denmark, England,
Finland and Belgium
•  We need to agree on the manual – how to conduct treatment to avoid treatment infidelity
•  We need to train therapist in MBT style
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Integration of the MBT model in practice and theory.
Investigate how the mentalizing capacity develop in expressive music therapy (improvisation, song writing, music
performing) and in receptive music therapy
•  Strehlow, G., & Lindner, R. (2015) Music therapy interaction patterns in relation to borderline personality
disorder. Identified 10 relational patternes
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Hannibal, N. (2014) Implicit and Explicit Mentalisation in Music Therapy in the Psychiatric Treatment of
People with Borderline Personality Disorder
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Workshop August 6, 1.15-2.45 pm Oslo:
Strehlow and Hannibal: How to work with mentalization
based treatment (MBT) perspective in improvisation based
music therapy.
Future clinical recommendations
When working with clients who have personality disorder:
•  Learn to mentalize your self and your clients
•  Adapt you musical intervention to “what ever” enhances or reestablish the ability to mentalize
•  Music therapy can improve attachment – implicit mentalization
and explicit mentalization
•  Some times even the unstable and difficult clients benefit form
treatment
Music Therapy Clinic at Aalborg University Hospital – Psychiatry
Inge Nygaard Pedersen
Associate Professor, head of clinic
Niels Hannibal
Associate Professor
Lars Rye Bertelsen
Clinical Music therapist
Lars Ole Bonde
Professor
Thank you for your attention
enjoy the view
Litteratur
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Hannibal, N., Petersen, B., & Windfeld, M. (2011). Gruppemusikterapi i
Dagbehandlingsregi: Opsamling på perioden 2003 til 2010. Musikterapi i
Psykiatrien Online, 6(1).
Hannibal, N., Pedersen, I. N., Hestbæk, T., Sørensen, T. E., & Munk-Jørgensen,
P. (2012). Schizophrenia and personality disorder patients' adherence to music
therapy. Nordic journal of psychiatry, 66(6), 376-379.
Hannibal, N. (2014). Implicit and Explicit Mentalisation in Music Therapy in the
Psychiatric Treatment of People with Borderline Personality Disorder. The Music
in Music Therapy: Psychodynamic Music Therapy in Europe: Clinical,
Theoretical and Research Approaches, 211.
Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Tervaniemi, M.,
Vanhala, M. & Gold, C. (2011). Individual music therapy for depression:
randomised controlled trial. The British journal of psychiatry, 199(2), 132-139.
Strehlow, G., & Lindner, R. (2015). Music therapy interaction patterns in relation
to borderline personality disorder (BPD) patients. Nordic Journal of Music
Therapy, (ahead-of-print), 1-25.
Stige, B. (2002). Culture-centered music therapy. Barcelona Publishers.
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Waltz, J., Addis, M. E., Koerner, K., & Jacobson, N. S. (1993). Testing the
integrity of a psychotherapy protocol: assessment of adherence and
competence. Journal of consulting and clinical psychology, 61(4), p. 620.
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Hawe, P., Shiell, A., & Riley, T. (2004). Complex interventions: how “out of
control” can a randomised controlled trial be?. BMJ: British Medical Journal,
328(7455), 1561.